Medication assisted treatment works. Why is it so hard for incarcerated people to access it?

Prison Policy Initiative updates for March 18, 2025 Exposing how mass incarceration harms communities and our national welfare

New report reveals successes and limitations of medications for opioid use disorder in New York state prisons [[link removed]] A new report from a New York prison oversight agency offers insights about the need for, and challenges of, implementing medication-assisted treatment in prisons. [[link removed]]

by Emily Widra

Substance use disorders are among the most pressing and least addressed medical conditions facing incarcerated people. While half of people in state prison [[link removed]] have substance use disorders — far outpacing the national prevalence of 8% [[link removed]] — only around 10% of people in state prison in 2019 had received clinical treatment [[link removed]] in the form of a residential treatment program, professional counseling, detoxification unit, or medication-assisted treatment. In recent years, advocates in states like New York have won hard-fought reforms to expand access to treatment for those behind bars. However, while we have some [[link removed]] information about substance use disorders and treatment among incarcerated people, it’s hard to get a good picture of how these reforms are being implemented without the insights and experiences of the people actually participating in these treatment programs.

In December 2024, the civilian oversight body of the New York state prison system — the Correctional Association of New York [[link removed]] (CANY) — published their report on medication-assisted treatment [[link removed]] (MAT) for opioid use disorder in New York prisons. The report, which found increasing numbers of people enrolling in the program each month since it was introduced, underscores the importance of expanding access to medications for opioid use disorder (MOUD). It also examines the inherent problems with providing healthcare under the supervision of correctional staff and the value of participant perspectives for evaluating program implementation.

Medication-assisted treatment is an evidence-based treatment approach that provides professional counseling or therapy combined with prescribed medications to reduce dependence on opioids. It is widely considered the “gold standard” of treatment for opioid use disorder. This treatment is overseen by medical providers and the medications prescribed are far less dangerous [[link removed]] than using heroin or other non-prescribed opioids outside of the treatment context. The length of treatment varies by individual [[link removed]], but there is no requirement that people continue MOUD forever: many people may benefit from months or years of treatment, while others may participate indefinitely.

Despite its promise, MOUD was the least common form of substance use disorder treatment in prisons: in 2016, only 1% of people with substance use disorders [[link removed]] in state and federal prisons reported receiving MOUD at any point since their admission. More recently, we found [[link removed]] that less than half (21) of all state prison systems and the federal Bureau of Prisons will continue MOUD for those receiving treatment prior to their prison admission. Only 33 state prison systems will initiate MOUD, and 14 of those will only initiate treatment in the weeks prior to release.

Only 12 states and the federal Bureau of Prisons offer both continuation and initiation of medications for opioid use disorder (MOUD) in every facility. Some state prison systems offer these opportunities at only some of their facilities, while others further restrict access to MOUD while incarcerated. For a handful of states, we were not able to find any evidence that they provide MOUD of any kind in state prisons.

Sourcing: Compiled by Prison Policy Initiative from the Jail & Prison Opioid Project [[link removed]] (last updated 2022) and A Review of Medication Assisted Treatment (MAT) in United States Jails and Prisons [[link removed]] from the California Correctional Health Care Services (2023), updated with information collected from news coverage and individual state prison system websites. For the data underlying this map, see the Appendix Table [[link removed]].

In 2021, the New York state legislature passed a law requiring MOUD programming [[link removed](ACTIVE)%20-%20Summary%20Relates%20to%20the%20establishment%20of%20a] in all state prisons to include all three FDA-approved medications and an “appropriate level of counseling.” This is crucial, as research shows that medication-assisted treatment — which definitionally involves access to therapy or counseling — works best when accompanied by psychosocial support and when providers are not limited in the medications they can offer. Other key components of the legislation include:

That the program is completely voluntary. Participation is not withheld from anyone who qualifies, and it cannot be denied because of a positive drug test or because of a past or present disciplinary infraction. People who qualify can participate in the program at any time during their incarceration. The program provides reentry planning and support including information on available treatment, assistance with medicaid enrollment prior to release, and a one-week supply of any necessary medications.

From 2022 to 2024, the Correctional Association conducted multiple visits to New York Department of Corrections and Community Supervision (DOCCS) facilities to evaluate the implementation of the medication-assisted treatment program in state prisons. The Correctional Association also published the Department of Corrections’ written response to their findings. While the Correctional Association’s monitoring reports should be interpreted as helpful feedback for program improvements and an opportunity to incorporate best practices into the healthcare offered in state prisons, the Department of Corrections took a defensive posture and often explicitly contradicted the experiences of directly impacted people; we have included some of these examples from the Department of Corrections response below.

Key findings from the Correctional Association of New York’s report

The Correctional Association report offers valuable qualitative and quantitative data regarding the New York prison system’s implementation of the MOUD policy and treatment program. Notably, the departmental policy is not publicly available online and is only accessible to incarcerated people in the prison law libraries or via public records request.

“The Department’s policy regarding MAT is set forth in Health Services Policy Manual (HSPM) Number 1.08. Incarcerated individuals are able to access the Department’s MAT policy in the Law Libraries of all correctional facilities. Copies may be obtained through the Freedom of Information Law (FOIL) process.” — New York State Department of Corrections response

To make matters worse, the statewide departmental policy does not include information about screening for participation, enrollment criteria, programming associated with MOUD, consequences and repercussions for misusing medications (i.e., “diversion”), or information about staff accepting, storing, and administering medications. When important information like enrollment criteria and consequences for a positive drug screening are not made explicit and accessible, potential participants can easily be discouraged from seeking necessary treatment.

Below, we discuss some of the key findings of the report, which are relevant to carceral facilities across the country.

Opioid use disorder and treatment availability in prisons

Substance use disorders are common throughout the criminal legal system. However, estimates of the prevalence of opioid use disorder specifically vary: researchers generally find that between 10% and 40% of people in prison meet the criteria for an opioid use disorder. Ten percent of all people in New York prisons (approximately 3,500 people) received MOUD in 2024, and since not everyone with an opioid use disorder receives treatment, the estimated prevalence of opioid use disorder in New York state prisons is likely greater than 10%.

The Department of Corrections is quick to point out in their response to the Correctional Association report that they have offered opioid use disorder treatment for years in the form of methadone for people who were returned to state custody from parole while receiving methadone or who entered prison while pregnant and receiving methadone. New York has indeed provided MOUD longer than many state prison systems. However, not nearly enough people in New York prisons had access to necessary care, as evidenced by the rapid increase of participation following the expansion of the treatment program to include all medications and operate at all facilities. From 2022 to 2023 alone, the Correctional Association found that the participation rate in the treatment program increased by a staggering 552%.

The prison system has also shifted away from methadone to buprenorphine as the program has expanded: in January 2023, 22% of people receiving MOUD were receiving methadone, but by March 2024 when the total participation numbers increased dramatically, only 12% of participants received methadone. Methadone treatment can be challenging to access inside and outside of prisons: by law, methadone must be dispensed as an oral medication at federally-certified opioid treatment programs. Frequently, people are required to attend these programs daily, as most people require daily doses of methadone, and the Department has 31 contracts with private medical providers for provision of these services at individual facilities.

Feedback from incarcerated people receiving MOUD

In a recent Department of Corrections survey of incarcerated people receiving MOUD, 92% of people agreed or strongly agreed that the treatment has been beneficial [[link removed]]. During the Correctional Association’s visits to facilities across the state, they encountered similarly strong support for the program:

“MAT has been a godsend. I was on [Office of Mental Health] but not anymore. MAT changed everything. It is an excellent program, and important for person’s transition home.”

“MAT program saved my life.”

“I started MAT, it has helped with mental health too — very beneficial.”

“Started MAT in February. First person at Hale Creek to get it. It is going great. I receive my medication as scheduled.”

Unfortunately, incarcerated people also report serious concerns about stigma and retaliation for participation in the treatment program. Many said they faced discrimination and instances where “staff call people crack heads and dope fiends” and “officers all believe we shouldn’t have the program, and they call us all drug addicts.” The Correctional Association also received multiple reports of staff assaulting people who they suspect are intoxicated or using drugs, regardless of treatment participation.

“It should be noted that the allegations of verbal, physical, and sexual abuse reported by some incarcerated individuals are not consistent with the experiences and sentiment of staff. There are thousands of daily interactions where staff maintain fairness, professionalism, and integrity when providing essential services, including the MAT program.” — New York State Department of Corrections response

Despite this defense, the Correctional Association observed skepticism regarding the utility of the program while meeting with health services teams, union representatives, and executive teams at numerous facilities. This included concerns about the “burden” on staff and resources required to implement the program. The Correctional Association reports staff endorsing “abstinence-only” approaches, and opposition to MOUD because staff perceive it as simply replacing one drug with another. This fundamental misrepresentation of medication-assisted treatment is pervasive — and deadly [[link removed]]- outside of prisons as well: medication-assisted treatment requires more interventions than simply prescribing a new medication. The FDA-approved medications, which are far less dangerous than heroin, fentanyl, or other non-prescribed opioids, assist other forms of treatment [[link removed]], including behavioral therapy, case management, patient advocacy, and other supportive services [[link removed]].

A crucial component of the law mandating medication-assisted treatment in New York prisons is that individuals cannot be barred from or removed from participation because of a positive drug screening or a disciplinary infraction, nor can they receive a disciplinary infraction for that positive screening. Despite these protections mandated by law, incarcerated people reported delays, denials, and interruptions to treatment after positive drug screenings, or for people with a history of misusing, selling, or distributing a prescribed medication (also known as medication diversion).

While the law specifically prohibits terminating or denying access to MOUD based on a positive drug screen, it is not clear that this information is provided to incarcerated people in any meaningful way. Instead, it is likely that people see the threat of a positive drug screen — which typically results in harsh, punitive sanctions with long-lasting consequences [[link removed]] — as a significant barrier to pursuing treatment, as the medications used in treatment can and do show up on drug screenings. This would be unclear even for the few incarcerated people who access the Department’s policy via the law library or public record request, because the policy does not mention that the law prohibits the exclusion of anyone from treatment because of a positive drug screen. It is also just as unlikely that most people in prison have easy or direct access to the text of the law that mandates MOUD treatment in prison.

Operational challenges to providing effective and comprehensive substance use treatment

The Correctional Association reported that in January 2024, 25% of health services positions were unfilled across all prisons in New York, and incarcerated people said that access to timely healthcare is limited, regardless of opioid use disorder or treatment participation. At some facilities, half of people interviewed described waiting more than a month to see a medical provider after requesting medical care. MOUD recipients have an appointment with a provider every 90 days to review their treatment and, between these appointments, participants can access health services through the regular sick call process. Clearly, providing specialized substance use disorder treatment to thousands of incarcerated people inevitably places additional responsibilities on the already-strained prison healthcare system, requiring more clinicians and health support staff [[link removed]] to adequately provide sustainable care. To meet this need, the Opioid Settlement Advisory Board allocated $11 million per year to the Department in fiscal years 2022 and 2023, and planned another $10 million in 2024. Still, the Department has struggled to properly staff facilities.

“Regarding staff vacancies, it is unclear what, if any, impact staff vacancies may have on MAT program participants. A review of the Department’s statistics provides no evidence that vacancy rates within Health Services have affected the MAT program participation and ongoing treatment. As of October 2024, statewide, the physician vacancy rate in DOCCS was 9% and the nursing vacancy rate was 41%, with vacancies supplemented with agency nursing staff.” — New York State Department of Corrections response

Providing MOUD in the prison context can be resource-intensive in other ways as well: for example, the Correctional Association reports that in several facilities, medical staff must travel to specific pharmacies to collect methadone. Not all facilities even have a pharmacy [[link removed]] to store and access medication appropriately, which is particularly alarming given all the health needs [[link removed]] of incarcerated people. In some facilities, staffing and space constraints also result in staff administering MOUD alongside regular sick calls or in the mess halls during meal time ( a serious health privacy concern [[link removed]]).

Some incarcerated people report being encouraged to take the monthly injectable medication instead of the medications that are required daily. While this may be less resource-intensive, the medication an individual takes is a decision to be made between an individual and their medical provider based on their specific circumstances [[link removed]] — not an opportunity to cut corners.

“Regarding the allegation that staff are encouraging or requiring participants to take monthly injectable formulations; inconsistencies with repercussions for diversion; wait times for medical care, and medication side effects, it is not possible to respond to general concerns as treatment is unique to each individual. Without identifying the individuals with a specific concern, or providing specific examples to investigate, we are not able to comment.” — New York State Department of Corrections response

Concerns about coordinating treatment, mental health services, and other programming

New York state law requires that each person receiving MOUD works with an “authorized specialist to determine an individualized treatment plan, including an appropriate level of counseling.” Alarmingly, the Correctional Association found no mention of counseling services in the Department’s policy and found no targeted mental health, peer support, or counseling services specifically available for MOUD recipients at any of the facilities visited — in other words, they are ignoring an essential component of this treatment. The health services team that administers the treatment program is responsible for referring patients to the Office of Mental Health (OMH) if mental health treatment is required in conjunction with medications. However, there are no medication-assisted treatment-specific referral procedures, and some prisons do not have full-time mental health staff on site.

Many people receiving MOUD are also mandated to participate in the Department of Corrections’ Alcohol Substance Abuse Treatment (ASAT) program, which requires periodic drug testing (MOUD recipients are also subject to random drug screening). However, a positive drug screening results in discharge from the ASAT program. Health services staff reported concerns to the Correctional Association that people who might benefit most from MOUD are not open about their substance use because they fear discipline or expulsion from ASAT or the work release program (these programs are typically required prior to release).

No policies addressing medication diversion

Jails [[link removed]] and prisons regularly [[link removed]] cite [[link removed]] medication diversion [[link removed]] — when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed — as a reason to refuse to provide MOUD. [[link removed]] In fact, research suggests that MOUD-related diversion occurs infrequently [[link removed]] and that expanded access to treatment actually diminishes [[link removed]] contraband medication use. Medication diversion is preventable [[link removed]], and researchers have identified a number of easy — and successful — interventions [[link removed](22)00028-9/abstract] to limit diversion in carceral settings. However, the law requiring MOUD access in New York state prisons does not mention diversion at all, ultimately leaving questions about identifying and responding to diversion in the hands of the Department of Corrections, individual facilities, and correctional staff. The Department of Corrections policy states that “every effort” should be made to provide MOUD, but leaves room for providers to ultimately decide to “taper the patient off the medication” if an individual is “persistent in being uncooperative with the treatment plan or is demonstrating risky behavior.” Potential MOUD recipients may be understandably concerned about beginning treatment without any clear information about how diversion is identified, substantiated, and what the consequences can be for the individual.

Conclusion

The Correctional Association report highlights the positive impact that expanded access to MOUD behind bars can have on people’s lives, and offers opportunities for the New York Department of Corrections and Community Supervision to improve their treatment program to better meet the needs of incarcerated people. Research suggests that MOUD during incarceration can have profound positive impacts on the health and mortality of participants after their release from prison: it’s associated with increased community-based treatment participation and reduced opioid use and overdoses after release [[link removed]]. Almost 4,000 people in New York state prisons receive MOUD, underscoring the need for comprehensive, supportive, and evidence-based substance use disorder treatment behind bars. These lessons are valuable beyond state borders: other jurisdictions can learn from New York’s experience implementing such a program and incorporate the Correctional Association’s recommendations from the start. Ensuring policies are publicly available to incarcerated people and the community, expanding substance use education for staff, reducing conflicts between MOUD programming and other programs, and guaranteeing access to appropriate counseling and peer support for medication-assisted treatment participants are all lessons that can help other states get off to a strong start and ensure incarcerated people have genuine access to the medical care they need.

***

For more information, including an appendix with policies around MOUD in all 50 state prisons systems and the Bureau of Prisons [[link removed]], as well as detailed footnotes, see the full version of this briefing [[link removed]] on our website.

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